Cycle 1
Health 2024-10-11 · Fire 2024-10-11
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
White Plains, NY
Epic Rehabilitation And Nursing At White Plains
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
120 Church Street, White Plains, NY
(914) 350-9010
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Epic Healthcare Management
Operator or chain grouping
Approved since
2020-04-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,805
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.15
Baseline 16.93% · Performance 17.19% · Measure score 9.15 · Achievement 9.15 · Improvement 0
Healthcare-associated infections
0.95
Baseline 7.66% · Performance 7.55% · Measure score 0.95 · Achievement 0.95 · Improvement 0
Total nurse turnover
6.94
Baseline 42.31% · Performance 35.29% · Measure score 6.94 · Achievement 6.94 · Improvement 3.52
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.78% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 436 · Observed rate 11.01% · Lower 95% interval 9.17% |
| Discharge to community | 60.31% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 496 · Observed rate 53.83% · Lower 95% interval 55.18% |
| Medicare spending per beneficiary | 1.61 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 99.52% |
95.27%
4.2 pts better
|
Numerator 416 · Denominator 418 |
| Falls with major injury | 0.24% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 418 |
| Discharge self-care score | 76.05% |
53.69%
22.4 pts better
|
Numerator 200 · Denominator 263 |
| Discharge mobility score | 83.65% |
50.94%
32.7 pts better
|
Numerator 220 · Denominator 263 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 22 · Denominator 418 · Adjusted rate 4.09% |
| Healthcare-associated infections requiring hospitalization | 7.55% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 372 · Observed rate 7.26% · Lower 95% interval 5.54% |
| Staff COVID-19 vaccination coverage | 14.07% |
8.2%
5.9 pts better
|
Numerator 37 · Denominator 263 |
| Staff flu vaccination coverage | 29.75% |
42%
12.2 pts worse
|
Numerator 105 · Denominator 353 |
| Discharge function score | 78.33% |
56.45%
21.9 pts better
|
Numerator 206 · Denominator 263 |
| Transfer of health information to provider | 99.02% |
95.95%
3.1 pts better
|
Numerator 101 · Denominator 102 |
| Transfer of health information to patient | 96.69% |
96.28%
0.4 pts better
|
Numerator 234 · Denominator 242 |
| Resident COVID-19 vaccinations up to date | 43.72% |
25.2%
18.5 pts better
|
Numerator 94 · Denominator 215 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
91.2%
7.2 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 97.9% · Q3 97.9% · Q4 98.9% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.3%
3.8 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.0%
1.7 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.1% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.7% |
18.5%
8.2 pts worse
|
11.4%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 31.9% · Q3 24.3% · Q4 23.2% · 4Q avg 26.7% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.1%
0.5 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 10.0% · Q3 4.8% · Q4 4.9% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.5%
1.2 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.6% · Q3 16.7% · Q4 11.6% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
14.8%
1 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 12.9% · Q3 13.3% · Q4 14.3% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.2% |
15.1%
4.9 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 12.1% · Q3 6.0% · Q4 3.2% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
15.5%
3.3 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 25.0% · Q3 14.5% · Q4 7.6% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.6%
0.2 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
20.8%
0.8 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 25.1% · Q3 13.8% · Q4 16.9% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
6.9%
2.1 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 10.7% · Q3 8.1% · Q4 3.8% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
76.7%
14.2 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 91.6% · Q3 92.3% · Q4 87.6% · 4Q avg 90.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
9.7%
0.8 pts worse
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 8.5% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.9% · Q3 1.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
78.8%
14.4 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
20.6%
1.2 pts worse
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 19.7% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-08 · Fire 2022-03-08
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-02-14 · Fire 2020-02-14
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-02
E · Potential for more than minimal harm
2022-03-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-05
E · Potential for more than minimal harm
2022-03-08
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-05-05
E · Potential for more than minimal harm
2022-03-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-05-05
D · Potential for more than minimal harm
2020-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-12-22
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Not marked corrected
E · Potential for more than minimal harm
2024-10-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-05
D · Potential for more than minimal harm
2023-08-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-29
Penalties and ownership
What sits behind the stars
Ownership
Westchester Health Care Properties I, LLC
5% Or Greater Direct Ownership Interest · Organization
Jozefovic, Herbert
5% Or Greater Indirect Ownership Interest · Individual
Neuman, Mark
5% Or Greater Indirect Ownership Interest · Individual
Brennan, Maura
W-2 Managing Employee · Individual
Feminella, Danielle
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Martine Center For Rehabilitation And Nursing
White Plains, NY
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
White Plains Center For Nursing Care, L L C
White Plains, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
The Grove At Valhalla Rehab And Nursing Center
Valhalla, NY
2-star overall rating with 1-star inspections with $76,339 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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